an early study used about 20 sessions per year; only 10 sessions were used in the two recent, large, randomized controlled trials (see next section)

Evidence for efficacy

a very careful randomized controlled trial (RCT) of 10 weeks of standardized CBIT in 126 children with DSM-IV Tourette’s Disorder or Chronic Tic Disorder showed clear evidence for superior efficacy of CBIT to a placebo therapy, with effect size of 0.68 for the YGTSS Total Tic Score (effect size was 0.30-0.64 for other outcome measures); 52.5% of children in the CBIT group were rated as “much improved” or “very much improved,” versus 18.5% in the control group, for a number needed to treat (NNT) of only 3 (Piacentini et al 2010)

this is one of the largest RCTs ever foranytreatment for tics! (as of 7/2011, the only larger RCT focused primarily on anti-tic efficacy was a 2008 Chinese study on a clonidine skin patch; two other studies with N=148 and N=136 subjects reported outcome data on tic severity but were primarily ADHD treatment studies in children with tics)

the benefit occurred almost entirely in the domain of tics, not in general psychological functioning (Woods et al 2011)

a companion RCT in 122 adults with TS (Wilhelm et al 2012) showed a significantly larger decrease in YGTSS scores (effect size = 0.57) and a significantly higher response rate (NNT = 5) in the CBIT group compared to the placebo treatment,which consisted of psychoeducation and supportive therapy (PST).This study was helpful in including follow-up data: at 6 months, 15 of the 24 patients who improved with CBIT during the RCT returned for follow-up, and 12 of the 15 (80.0%) showed continued benefit.

there are a number of other less rigorous studies and detailed case reports / small series:

one study randomly assigned 10 subjects with DSM-IV Tourette syndrome to active treatment or a wait list; the immediate treatment group had significantly better response at the end of the wait period (Mann-Whitney U test, 1-tailed p<0.025), which persisted (~90% reduction in tics after 12 months); the group that started after 3 months of wait list remained stable until treatment began, then improved rapidly to similar levels; importantly, “the subjective urge to perform the tic was reported by the present subjects to have been greatly reduced or absent” (Azrin & Peterson 1990)

a large RCT randomly assigned patients with chronic tic disorders to active treatment with HRT (N=47) or to a wait list control group (N=22); a treatment manual was used; wait-list and active treatment groups differed significantly in mean self-reported tic scores at the end of the wait list period (p < 0.001) and after 4 months (wait list, 21+31; active treatment, 7+16). At 2-year follow-up, 52% rated tics as “75-100% controlled”; ratings of patient videos and ratings by a friend or family member gave similar results (O’Connor et al 2001; O’Connor 2001, 2003)

in 2003, Wilhelm and colleagues reported a randomized controlled study of habit reversal therapy (HRT) versus supportive psychotherapy (intended to serve as a control) in 32 patients with DSM-IV Tourette’s disorder. Mean tic severity scores from the Yale Global Tic Severity Scale after 14 sessions of treatment were significantly better in the HRT group (19.8+7.6) than in the control group (26.9+9.2, p < 0.05 by t test; p < 0.01 after controlling for baseline tic severity by ANCOVA). In addition, functional impairment ratings improved significantly, and significantly more, in the HRT group (p < 0.01 for each comparison). Patients rated themselves as significantly more improved with HRT (CGI score, mean 2.13 vs 3.55 in the supportive therapy group; p < 0.01). Unfortunately, these ratings were not done blind to treatment status.

RCT of group HRT vs group education in 33 children with TS or Chronic Tic Disorder (Yates et al., 2016). More improvement in tics with group HRT.

one review concluded that the overall efficacy of HRT for tics is ~90% at home, ~80% in clinic, but later studies are not quite that enthusiastic

improvement seems to be independent of medication status or age, and generalizes over different settings

Evidence regarding side effects:

The two large RCTs (Piacentini et al 2010; Wilhelm et al 2012) prospectively monitored side effects and found none

the Discussion sections of these two reports specifically address and refute concerns by prominent clinicians who do not understand CBIT well, underestimate its benefit, expect side effects from CBIT that do not occur (or at worst are rare), and hence relegate it to a secondary role in treatment

The possibility that suppressing one tic as part of CBIT would lead to substitution of other tics was specifically examined and shown not to happen (Peterson et al 2016)

however, even in older studies, there was no evidence of symptom substitution from videotape review or self-report (e.g., Azrin and Peterson 1990)

note that detailed questioning and blinded videotape review were performed in some studies; results suggest that patients generally end up using the behavior therapy techniques rarely, because tic frequency declines (i.e. patients don’t just incorporate the behavior therapy technique as a new tic)

Method (the original components of HRT are described first; seeWoods and Miltenberger 1995 for an excellent review of what components of HRT actually work)

Awareness Training

first visit: patient & significant other to record frequency of each tic for a specified duration each day (10min or all day depending on frequency of tic); videotape subject at beginning of each session

Reponse Description Procedure: describe the detail of each tic to therapist, using mirror and/or videotape

Response Detection Procedure: therapist alerts subject each time a tic is observed, with progressively less intrusive warnings

Early Warning Procedure: subjects practice self-detection of earliest signs or sensory cues before a tic

Situation Awareness Training: subjects identify situations, persons or places in which symptoms were better or worse

Relaxation Training: progressive muscular relaxation, deep breathing, visual imagery, self-statements of relaxation; taught duringfirst visit and instructed to practice at least daily for 10-15 minutes as well as for 1-2 minutes whenever anxious or whenever they have a tic

example: for head jerking back, the CR could be contraction of the neck flexors with chin slightly down and in

example: for a vocal tic, the CR could be slow rhythmic deep breathing through the nose with the mouth closed

The competing response is to be done for 3 minutes after each tic or sensation that a tic is about to occur.

Research suggests that only contingent use of the competing response is helpful (i.e. every time a tic or sensory tic happens), while non-contingent (e.g. random or scheduled) use of the competing response is not (Miltenberger and Fuqua 1985).

“Miltenberger, Fuqua and McKinley (1985) found that the awareness training and competing response training components used together were effective as the entire habit reversal program in suppressing muscle tics” (quoted from Miltenberger and Fuqua 1985).

Also, a study in 2 patients suggested that the competing response (CR) need not be truly competing; e.g. for a head-turning tic, a CR of pressing the foot into the floor works just as well as a head-turning CR (Sharenow et al 1989).

“The tic that was the most frequent or most disruptive was treated first after the relaxation training. At least one session was devoted to training the individual to employ the Competing Response Procedure both during the session and during the following week in the subject’s natural home setting. In subsequent sessions, each additional tic was treated one at a time until a specific competing response had been established for each tic.” (Azrin and Peterson 1988 p.349)

Contingency Management

family instructed to comment favorably on signs of improvement (and in Azrin and Nunn 1973 report, remind the patient to “do exercises” if he/she forgot)